Ohio Administrative Code
Title 5160:1 - Eligibility
Chapter 5160:1-3 - Medicaid for the Aged, Blind, or Disabled (ABD)
Section 5160:1-3-02.1 - Medicare premium assistance programs (MPAP)

Universal Citation: OH Admin Code 5160:1-3-02.1

Current through all regulations passed and filed through September 16, 2024

(A) This rule sets forth the eligibility criteria and benefits for the medicare premium assistance programs (MPAP). The programs are: qualified medicare beneficiary (QMB), specified low-income medicare beneficiary (SLMB), qualified individual (QI-1), and qualified disabled and working individual (QDWI).

(B) Definitions.

(1) "Eligible," for the purpose of this rule, means an individual meets all the requirements to enroll in MPAP.

(2) "Enrolled," for the purpose of this rule, means an individual is in receipt of benefits under a medicare health plan.

(3) "Entitled," for the purpose of this rule, means an individual has coverage under medicare through the social security administration (SSA).

(4) "Family," for the purposes of MPAP, means the following persons living in the same household as the individual for whom medicare premium assistance is sought or received:
(a) The individual; and

(b) When the individual is a minor, the biological parents, adoptive parents, step-parents, legal guardians, or legal custodians of the individual; and

(c) The spouse of the individual and of any persons described in paragraph (B)(4)(b) of this rule; and

(d) The minor biological, adopted, or stepchild(ren) of the individual and of any persons described in paragraphs (B)(4)(b) and (B)(4)(c) of this rule.

(5) "Family of the size involved" means "family" as defined in paragraph (B)(4) of this rule.

(6) "MPAP" means any or all of the medicare premium assistance programs: QMB, SLMB, QI-1, and QDWI.

(7) "MPAP resource limit" means the maximum amount of countable resources allowed under section 1905(p)(1) of the Social Security Act (as in effect October 1, 2023), as adjusted annually according to the change in the consumer price index for urban areas (CPI-U).

(8) "Qualified," for the purpose of this rule, means an individual is eligible to receive benefits under a medicare health plan, whether or not the individual has applied for those benefits.

(9) "QDWI" means the qualified disabled and working individual program established by section 1905(s) of the Social Security Act (as in effect October 1, 2023). This program is sometimes referred to as the qualified working disabled individuals (QWDI) program.

(10) "QI-1" means the qualified individual group, described in section 1902(a)(10)(E)(iv) of the Social Security Act (as in effect October 1, 2023).

(11) "QMB" means the qualified medicare beneficiary group described in section 1905(p)(1) of the Social Security Act (as in effect October 1, 2023).

(12) "SLMB" means the specified low-income medicare beneficiary group described in section 1902(a)(10)(E)(iii) of the Social Security Act (as in effect October 1, 2023).

(C) The income standards for the medicare premium assistance programs (MPAP) are as follows:

(1) The QMB income standard is one hundred per cent of the federal poverty level for the family of the size involved.

(2) The SLMB income standard is greater than one hundred per cent of the federal poverty level and up to a maximum one hundred twenty per cent of the federal poverty level for the family of the size involved.

(3) The QI-1 income standard is greater than one hundred twenty per cent of the federal poverty level and up to a maximum one hundred thirty-five per cent of the federal poverty level for the family of the size involved.

(4) The QDWI income standard is two hundred per cent of the federal poverty level for the family of the size involved.

(D) To be eligible for a medicare premium assistance program, an individual must meet all of the following conditions:

(1) Be qualified for coverage under medicare part A (part A).
(a) An individual otherwise qualified for QMB must be enrolled in either part A or medicare part B (part B) for the administrative agency to provide benefits under this rule.

(b) An individual otherwise qualified for SLMB must be enrolled in part A for the administrative agency to provide benefits under this rule.

(c) An individual otherwise qualified for QI-1 must be enrolled in part A for the administrative agency to provide benefits under this rule.

(d) An individual otherwise qualified for QDWI must be enrolled in part A under section 1818A of the Social Security Act (as in effect October 1, 2023). Coverage can be identified as being provided under section 1818A of the Social Security Act when the individual meets the following criteria:
(i) Has not reached sixty-five years of age; and

(ii) Has lost disability benefits under Title II of the Social Security Act (as in effect October 1, 2023) solely due to earnings in excess of the substantial gainful activity (SGA) level established by the SSA; and

(iii) Is paying a premium for part A coverage; and

(iv) Has provided no document or communication from the SSA indicating another basis for part A coverage.

(2) For QMB, SLMB, and QI-1, have countable resources that do not exceed the MPAP resource limit as defined in paragraph (B)(7) of this rule for an individual or the MPAP resource limit for a couple (the individual and the individual's spouse). Countable resources shall be determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(3) For QDWI, have countable resources that do not exceed twice the maximum amount of resources that an individual or couple (the individual and the individual's spouse) may have under the supplemental security income (SSI) program. Countable resources shall be determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(4) Have countable income, as determined in accordance with paragraph (E) of this rule, within the MPAP income standards as set forth in paragraph (C) of this rule.

(5) For QI-1 and QDWI, be otherwise ineligible for medical assistance in accordance with Chapters 5160:1-3, 5160:1-4, 5160:1-5, and 5160:1-6 of the Administrative Code.

(6) Meet the application, conditions of eligibility, and verification requirements set forth in Chapter 5160:1-2 of the Administrative Code.

(E) Countable income shall be determined in accordance with Chapter 5160:1-3 of the Administrative Code.

(1) The annual cost of living adjustment (COLA) shall be deducted from the individual's income beginning in January of each year and continuing through the end of the month after the month in which the updated federal poverty guidelines are published in the Federal Register.

(2) The income of both the individual and the individual's spouse shall be determined in accordance with rule 5160:1-3-03.1 of the Administrative Code and applying all exclusions listed in rule 5160:1-3-03.2 of the Administrative Code, except that the twenty-dollar general income exclusion and the exclusion of the first sixty-five dollars of earned income shall be applied only once to a married couple in the MPAP eligibility determination.

(3) The deeming provisions set forth in rule 5160:1-3-03.3 of the Administrative Code do not apply to MPAP eligibility determinations.

(F) Application of income standards.

(1) When the individual is a minor, the countable income of the following individuals is combined and compared to the income standards set forth in paragraph (C) of this rule for the family of the size involved:
(a) The individual; and

(b) The individual's biological parents, adoptive parents, step-parents, legal guardians, or legal custodians; and

(c) When married, the individual's spouse.

(2) The income of the individual combined with the income of the individual's spouse is compared to the income standards set forth in paragraph (C) of this rule for the family of the size involved.

(G) Application of resource standards.

(1) The countable resources of the individual combined with the countable resources of the individual's spouse are compared to the resource standards set forth in paragraphs (D)(2) and (D)(3) of this rule.

(2) The deeming provisions set forth in rule 5160:1-3-05.20 of the Administrative Code do not apply to MPAP eligibility determinations.

(H) Coordination of enrollment. When the individual is eligible for benefits under this rule, the county department of job and family services (CDJFS) shall coordinate the individual's receipt of benefits.

(1) When the individual is or has ever been in receipt of part A or part B benefits, the CDJFS shall approve MPAP benefits for the individual in the electronic eligibility system.

(2) When the individual has never received part A or part B benefits, the CDJFS shall:
(a) Inform the individual that the Ohio department of medicaid (ODM) can not pay medicare premiums until the individual has enrolled in part A or part B through the SSA; and

(b) Advise the individual to apply for part A or part B benefits through the SSA, and advise the individual that the CDJFS will assist upon request; and

(c) Advise the individual to report the approval of part A or part B benefits to the CDJFS immediately, so payment of premiums can be approved; and

(d) Approve MPAP benefits for the individual in the electronic eligibility system upon being informed that the individual has been enrolled in part A or part B by the SSA.

(I) Coverage periods.

(1) The effective date of QMB coverage is the first day of the month after the month in which the administrative agency approves QMB benefits. No retroactive coverage is available for QMB.

(2) Eligibility for SLMB benefits begins no earlier than the third month prior to the month of application, provided the individual met all eligibility criteria including enrollment in part A during the three-month period.

(3) Eligibility for QI-1 benefits begins no earlier than the third month prior to the month of application, provided the individual met all eligibility criteria including enrollment in part A during the three-month period.

(4) Eligibility for QDWI benefits begins no earlier than the third month prior to the month of application, provided the individual met all eligibility criteria including enrollment in part A during the three-month period.

(5) Eligibility for payment of medicare premiums under this rule ends on the earliest of the following dates:
(a) The last day of the month in which the individual dies; or

(b) The last day of the last month in which the individual is entitled to part B benefits; or

(c) The last day of the last month in which the individual meets the eligibility criteria for MPAP, if notice was provided to the centers for medicare and medicaid services (CMS) no later than the twenty-fifth day of the second month of ineligibility; or

(d) The last day of the second month before CMS receives notice the individual was no longer eligible for MPAP, when notice was not provided within the time limit identified in paragraph (I)(5)(c) of this rule.

(J) Benefits.

(1) When the individual is eligible for QMB, the administrative agency shall pay the individual's:
(a) Premiums for part B and, when a premium is charged, for part A; and

(b) Medicare deductibles; and

(c) Medicare co-pays; and

(d) Medicare coinsurance costs.

(2) When the individual is eligible for SLMB or QI-1, the administrative agency shall pay the individual's part B premiums.

(3) When the individual is eligible for QDWI, the administrative agency shall pay the individual's part A premiums.

(4) The medicare prescription drug benefit program (part D) is not covered by MPAP.

(K) Administrative agency responsibilities. The administrative agency shall:

(1) Explore eligibility for medical assistance and for all MPAP categories when a medical assistance applicant is qualified for part A. The agency shall advise the individual:
(a) Of the categories of medical assistance or MPAP for which the individual is eligible, the individual's right to decline payment of premiums, co-pays, or coinsurance costs, and the effect of declining MPAP payments; and

(b) That when the individual is qualified for benefits under part A or part B, ODM is prohibited from paying for prescriptions on behalf of that individual, whether or not a premium would be charged for those benefits.

(2) Determine the individual's eligibility for QMB and when eligible:
(a) Approve QMB benefits effective the month after the administrative agency approves QMB coverage; and

(b) For individuals who are not receiving free part A, but who could receive part A benefits by paying a premium, coordinate enrollment in parts A and B with SSA.

(3) Determine the individual's eligibility for SLMB and, when eligible, approve SLMB benefits in accordance with paragraph (I)(2) of this rule.

(4) Determine the individual's eligibility for QI-1 and, when eligible, approve QI-1 benefits in accordance with paragraph (I)(3) of this rule.

(5) Determine the individual's eligiblity for QDWI and, when eligible, approve QDWI benefits in accordance with paragraph (I)(4) of this rule.

(6) Deny benefits under this rule when:
(a) Any criterion under this rule is not met; or

(b) Any of the conditions for denial set forth in rule 5160:1-2-01 of the Administrative Code are met.

(7) Discontinue benefits under this rule when :
(a) An individual no longer meets the eligibility criteria for any covered group under this rule; or

(b) Any of the conditions for discontinuance set forth in rule 5160:1-2-01 of the Administrative Code are met; or

(c) The individual was eligible for benefits under QI-1 but becomes eligible for another category of medical assistance.

(8) Coordinate enrollment with the individual, the SSA, and ODM's buy-in unit.

(L) Individual responsibilities.

(1) Inform the CDJFS of any actions by the SSA on the individual's application for part A or part B, or any changes in the individual's part A or part B coverage.

(2) Adhere to the individual responsibilities set forth in rule 5160:1-2-08 of the Administrative Code.

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